If you were a Little Miss or Mr Man who would you be? Little Miss Naughty or Little Miss Fabulous? Mr Bump or Mr Perfect? Or would you be one of the brand new Little Miss or Mr Men; Little Miss Brave or Mr Calm? The choices seem almost endless! I like to think I’m Mr Clever, but ECIC thinks I’m more like Mr Silly… thanks a lot Little Miss Trouble!
“We have a septic lady who has just returned from a trip to India. She also has a headache and diarrhoea. We think she might have typhoid but want to cover for meningitis as well as this. What do you suggest?”
The Microbiologist listened as the Emergency Department (ED) Consultant expanded on the story with where exactly the patient had been in India, what she had been doing there and what pre-travel vaccinations she had had. It was a great presentation and showed that the Consultant had clearly been listening to the teaching on fever in a returning traveller that the Microbiologist had given the week before!
“Okay, she’s been to the North of India, we’d better cover for XDR typhoid as well as meningitis and other potential causes of sepsis. The best thing to do is start IV Meropenem 2g TDS, and if it’s not meningitis then we can reduce the dose to 1g later” replied the Microbiologist.
“Isn’t IV Ceftriaxone the normal first line for typhoid?” asked the ED Consultant.
“It is” replied the Microbiologist, “unless you have the XDR typhoid which is currently causing mayhem in Pakistan next to India, XDR is Ceftriaxone resistant and so you need Meropenem instead.”
“Crikey!” exclaimed the ED Consultant, “long gone are the days when I could treat this with Ampicillin…I’m sure Typhoid Mary would have accepted Ampicillin!”
“We all feel a little old these days, I find it’s more about the mileage not so much the years…!” said the Microbiologist.
“May I discuss a patient with you please?” asked the ward Doctor.
“You want to discuss a patient? Okay, but this telephone line is terrible” replied the Microbiologist, wondering whether the “new” telephone system in the hospital was really an “improvement”.
“Sorry, it’s a bit difficult to hear you” said the ward Doctor, “I wanted to discuss a patient with enlarged glands in the neck.”
“What?!” exclaimed the Microbiologist, “you think your patient has glanders! Why do you think they have glanders?”
“Yes, they have large glands …in their neck.”
“Glanders is extremely rare, and very severe, have you started antibiotics?”
“Yes, we want to start antibiotics.”
The telephone line was still terrible, and the Microbiologist was starting to get really worried. He looked at the number listed on the phone recognising it as the Acute Medical Unit where patients were admitted.
“I’m coming to you, wait for me there” said the Microbiologist putting down the phone.
“Blooming Microbiologist,” muttered the ward Doctor, “he just hung up on me!”
What is glanders?
Glanders is principally an infection of “solipeds” …that’s horses, donkeys and mules to you and me. It is caused by the bacterium Burkholderia mallei, a small, Gram-negative, oxidase positive, bacillus, that only replicates inside its living host being unable to survive in the environment. B. mallei is not to be confused with a similar bacterium I blogged about way, way, back in 2017 called Burkholderia pseudomallei which causes a condition called melliodosis and which is able to survive in the environment!
“Is that the Duty Microbiologist? Can I please discuss a patient with you and get your advice?” asked the Junior Doctor.
The Microbiologist nearly fell off his chair… people were rarely that polite when calling…
“Certainly, what can I help you with?” he replied, feeling immediately predisposed to being happy and helpful. (A very weird and unfamiliar feeling for the Microbiologist!)
“I have a complex patient who had a kidney transplant about 6 months ago who keeps getting UTIs. She has had a number of positive urine cultures and she feels better after being treated, but when the antibiotics stop, she quickly becomes symptomatic again. We’re wondering where we go from here. Should we try a longer course of antibiotics to see if that helps or would she benefit from antibiotic prophylaxis?”
The Microbiologist had been listening intently.
“This could be BK virus infection causing ureteral stenosis. Have you imaged the transplanted renal tract?”
“Beaky what virus?” asked the Junior.
And it had been going so well….
The Microbiologist sat quietly eating his lunch, partially hidden behind a pot plant in the staff canteen, when he sensed someone standing behind him. “Damn!” he thought, thinking he had hidden well enough to prevent his lunch being interrupted with any clinical questions... but clearly not.
Looking around he met the gaze of the Cardiology Registrar who was clearly waiting to make eye contact before launching into “the patient’s story”!
…“I have a patient in her early twenties who came in with a fever and a rash, but over the last few days she has started to go into heart failure”.
The Registrar had been in the Microbiologist’s teaching session early in the week, and had clearly “swotted up” after being asked questions he didn’t know the answers too.
The Cardiology Registrar then delivered the “piece de resistance” and declared “I think this might be Rheumatic Fever”.
“Okay, this is going to sound odd, but can we test a baby for RSV?” asked the Paediatrician.
“You do realise it’s July, don’t you? I mean I know we’ve all been locked in our houses for months, it’s raining and the radio played a Christmas song this morning…but it’s still summer!” exclaimed the Microbiologist.
“I have a patient in his 40s who has been coughing for several weeks and is starting to get fed up. The cough is keeping him, and his wife, awake, so he’s taken to sleeping in the spare room in order to give her some respite but it’s not ideal. I’ve done a chest x-ray and it looks okay, and he’s not really coughing anything up in order to send to it to the lab for culture. What antibiotics do you think I should give?” said the GP.
Malaria is a common parasitic infection spread by mosquitos. WHO estimate that there were 229 million cases occurring during 2019, with 409,000 deaths of which 274,000 were children under 5 years old. This is both staggering and depressing because malaria is both preventable and treatable… and yet every year over 400,000 people die who shouldn’t. That means more people have died in the last 8 years from malaria than have died in the Covid-19 pandemic.
Trillions of pounds have been spent during the Covid-19 pandemic supporting the economies of developed countries and yet only about 3 billion pounds has been spent in total trying to fight malaria. Why the difference? It could be that Covid-19 had the potential to cause more death and disease than malaria, but then why not spend the trillions on the health response rather than the economy? Could it have anything to do with the fact that 94% of cases and deaths from malaria occur in Africa rather than Europe and the USA?
Now we all know we should go and get our Covid-19 vaccine but wouldn’t it be great if there was an effective vaccine against malaria too? The WHO want a malaria vaccine that is at least 75% effective by the year 2030. Surely if there was something like that it would be all over the news; all that death and disease prevented. Well there is a promising vaccine… it just seems to have got a bit lost in all the Covid-19 noise… it is being trialled by those clever scientists from Oxford again, but it does have a rubbish name…!
The Microbiologist gave a big sigh. It was a beautiful spring day outside, perfect for hitting the forest trails, and here he was sat at the duty desk advising on how to treat athletes foot… he sighed again…
The phone rang and with a heavy heart the Microbiologist answered.
“I have a patient who I think has a fungal infection” said the voice on the other end of the line.
“Here we go again” thought the Microbiologist.
“What kind of fungal infection?”
“I’m not really sure. He has a lump on his foot which has been getting worse since he came back from Africa a few months ago” said the voice.
The Microbiologist sat up straight. This was more like it, something weird and wonderful.
“Who am I speaking to? What was your patient doing in Africa? Did he hurt himself, cuts to his feet, anything like that?”
“Oh sorry, it’s the Dermatologist here, busy clinic and forgot my manners. The patient was volunteering, helping to build a school in a rural village, he was there for a long time and I suspect as he was wearing flip-flops a lot, he had many scratches and cuts to his feet during that time. I thought it might be another case of sporotrichosis, but there is no sporotrichoid spread and the lump is completely painless. There does look to be a sinus forming as well. What do you think?”
“It does sound like eumycetoma. Here’s what I think we should do…”
The patient was in his 50s and had been previously fit and well, but had become unwell a few months earlier after working in his garden on a hot sunny day. After putting his shirt back on and coming inside his arm had started to itch. This had rapidly spread to his chest and then all over his body. It felt to the patient like he had insects crawling under and over his skin. Nothing helped. He bathed, got changed, took an antihistamine, all to no avail.
The following morning, after a terrible night’s sleep, the patient was covered in a scab like rash and the itching continued. He saw his GP who thought this was a probable contact dermatitis and gave advice accordingly.
Over the next couple of months things went from bad to worse. The itching continued, he couldn’t sleep, the rash and scabs spread, and he became convinced he was infested with bugs. In fact, the patient was able to squeeze “bug stuff” out of the scabs for his GP to see! The GP took skin samples and sent them off to the microbiology lab, but no parasites were seen and nothing infectious grew.
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